The Relationship between Gears and Breastfeeding

It is estimated that improving exclusive breastfeeding rates worldwide could prevent 800,000 infants from dying every year. The good news is that we now have at our disposal the evidence based tools to make successful breastfeeding promotion happen not only at a small but also at a very large scale. What if we think about fixing low breastfeeding rates in Latin America and the Caribbean using gears?

I recently led a team of Yale researchers to help identify the key ingredients of national breastfeeding programs that have been proven to be effective, and to find out how to link them together in a single model. Our approach was to review the scientific literature, national case study reports from international agencies including UNICEF and WHO, and to conduct in–depth interviews with breastfeeding policy makers. As in an engine, the resulting model was named the “Breastfeeding Gear Model.” This model identified the key “gears” that need to be in place for national breastfeeding programs or “engines” to be successful at promoting optimal breastfeeding behaviors, including exclusive breastfeeding for six months.

The first “gear” is evidence-based advocacy that eventually leads to the political support (second “gear”) that is needed for enacting legislation (third “gear”) and securing the release of resources (fourth “gear”) to provide training on and implement key hospital and community based initiatives such as the UNICEF/WHO Baby Friendly Hospital Initiative and community based breastfeeding peer counseling models (fifth “gear”). Successful national programs have also established behavior change communications promotion campaigns that make extensive use of mass media and social marketing principles (sixth “gear”). Successful national programs have invested on process and impact evaluations to understand how the system as a whole is functioning (seventh “gear”).

The work of the peripheral “gears” of the model is steered by a breastfeeding national committee (master “gear”) that sets and monitors goals, recommends system improvements, and provides a flexible structure that is decentralized but allows strong coordination from the municipal to the state and national level. This, of course, requires having adequate management information systems in place.

So what’s the big deal here? Why are evidence-based practical scaling up models such as the “Breastfeeding Gear Model” relevant? Well, because they provide an easy–to-understand roadmap that allows decision makers to prioritize investments so that complex public health systems, including national breastfeeding promotion programs, can be successfully scaled up. For example, I recently had the pleasure of advising the minister of health of a country who was very puzzled as to why exclusive breastfeeding rates were not showing improvements even though he had provided the highest level of political support for this to happen.

After sharing the “Breastfeeding Gear Model” he immediately understood that most of the “gears” were either not in place or that they were in serious need of tune-up or repairs. As a result, immediate actions were recommended including legislation for improved worksite breastfeeding support, enforcement of the WHO code for ethical marketing of breast milk substitutes, and launching a re-certification process for Baby Friendly facilities.

I believe that the science of scaling-up of public health programs will continue making enormous strides over the next years. I’m very proud that the breastfeeding sector has already made, and will continue to make, enormous contributions to achieve what, at the end of the day, should matter the most- providing access to evidence-based cost-effective services for all. I think that over two decades ago I made the right choice when deciding to focus my doctoral dissertation work on promoting one behavior in my native Mexico that has turned out to be one of the most cost-effective ways of promoting the wellbeing of children and women all over the world, breastfeeding!

Rafael Pérez-Escamilla, PhD is a Professor of Epidemiology and Public Health. Yale School of Public Health

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